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Mon-Fri: 9:00 AM - 5:00 PM
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Office: 240-869-9325
Fax: 571-589-0141
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Flu and COVID POLICY AND PROCEDURES FOR STAFF
Contact Us
Home
About Us
Our Services
Careers
Testimonials
Resources
Forms
Application for Employment
VA Sworn Disclosure
Flu and COVID POLICY AND PROCEDURES FOR STAFF
Contact Us
Book An Appointment
240-869-9325
[email protected]
Facebook-f
Instagram
Linkedin-in
Home
About Us
Our Services
Careers
Testimonials
Resources
Forms
Application for Employment
VA Sworn Disclosure
Flu and COVID POLICY AND PROCEDURES FOR STAFF
Contact Us
Home
About Us
Our Services
Careers
Testimonials
Resources
Forms
Application for Employment
VA Sworn Disclosure
Flu and COVID POLICY AND PROCEDURES FOR STAFF
Contact Us
Book An Appointment
Office: 240-869-9325
Fax: 571-589-0141
[email protected]
Facebook-f
Instagram
Linkedin-in
Book An Appointment
Application for Employment
PERSONAL DATA
Date Application Completed
MM slash DD slash YYYY
Date of Interview (OFFICE USE ONLY)
MM slash DD slash YYYY
Date of Hire (OFFICE USE ONLY)
MM slash DD slash YYYY
Name
(Required)
First
Middle
Last
Email
(Required)
Social Security Number
Home Phone
Other Number
Pager / Cellular Number
Address (If less than one year provide your previous address)
City
State
Zip Code
Length of Residence
Previous Address
City
State
Zip Code
Length of Residence
JOB INTERESTS
Position Applying For:
How were you referred to us?
Date Available for Work?
MM slash DD slash YYYY
Anticipated Wage
Please check the specialty area(s) that best match(es) your experience / education and interested
Homecare
Medical / Surgical
IV Therapy
Intermittent Care
Private Duty
Hospice
Rehabilitation
Pediatrics/Maternal Child
Supplemental Staffing
Residential Care
Nursing Home
Nursing Home
Geriatric
Psychiatric
Homemaking
Please indicate your availability or interests below
Work Status
Full Time
Part Time
Shifts Available
Days
Nights
Evenings
Visits Only
Days Available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
EDUCATION
Choose the Highest level of education completed
1
2
3
4
5
6
7
8
9
10
11
12
High School Diploma
Associate
Bachelors
Masters
Name of College or Undergraduate Education / School
Degree
Year Graduated
Name of College or Undergraduate Education / School
Degree
Year Graduated
LICENSE / CERTIFICATIONS / EXAMINATIONS
Type of License
State of Issue
Expiration Date
MM slash DD slash YYYY
License Number
Any restrictions or pending actions against license?
CPR Expiration
MM slash DD slash YYYY
Last Physical Examination
MM slash DD slash YYYY
Last TB / Chest X-ray
MM slash DD slash YYYY
GENERAL INFORMATION
Are you legally authorized to work in the USA
Yes
No
Have you ever been convicted or plead guilty of a felony or a misdemeanor crime?
Yes
No
If you become an employee of this Agency you will be required to provide documentation proving your eligibility to work in the USA. If Yes –explain:
Have you ever been employed by this agency or one of its subsidiaries? In case of emergency, notify
Yes
No
If yes, give location and dates:
Phone
Relationship
References
Give the names of three persons not related to you to whom you have known at least 1 year
Name
Address
Phone
Yrs acquainted
Name
Address
Phone
Yrs acquainted
Name
Address
Phone
Yrs acquainted
List any foreign language(s) and check the box that best describes your skill level.
Language
Read and write
Read and speak
Speak only
Choose the box that best describes your skill level
Language
Read and Write
Read and Speak
Speak Only
In case of Emergency notify :
Address
Relationship
Phone
WORK HISTORY
Company Name (present or most recent employer)
From (Employment Dates)
MM slash DD slash YYYY
To (Employment Dates)
MM slash DD slash YYYY
Company Address
City
State
Wage (Per Hour)
Wage (Annual)
Describe your Job Responsibilities and Duties
Supervisor’s Name
Telephone Number
May We Contact
Yes
No
Reason for Leaving?
Company Name (present or most recent employer)
From (Employment Dates)
MM slash DD slash YYYY
To (Employment Dates)
MM slash DD slash YYYY
Company Address
City
State
Wage (Per Hour)
Wage (Annual)
Describe your Job Responsibilities and Duties
Supervisor’s Name
Telephone Number
May We Contact
Yes
No
Reason for Leaving?
Company Name (present or most recent employer)
From (Employment Dates)
MM slash DD slash YYYY
To (Employment Dates)
MM slash DD slash YYYY
Company Address
City
State
Wage (Per Hour)
Wage (Annual)
Describe your Job Responsibilities and Duties
Supervisor’s Name
Telephone Number
May We Contact
Yes
No
Reason for Leaving?
Company Name (present or most recent employer)
From (Employment Dates)
MM slash DD slash YYYY
To (Employment Dates)
MM slash DD slash YYYY
Company Address
City
State
Wage (Per Hour)
Wage (Annual)
Describe your Job Responsibilities and Duties
Supervisor’s Name
Telephone Number
May We Contact
Yes
No
Reason for Leaving?
In accordance with Title VI of the Civil Rights Act of 1964 and its implementing regulation, Maryam Home Health LLC. is an EQUAL OPPORTUNITY EMPLOYER and WILL NOT DISCRIMINATE AGAINST RACE, COLOR, SEX, CREED, NATIONAL ORIGIN ORCOMMUNICABLE DISEASE AS DEFINED IN SECTION 504 OF TITLE VI. In accordance with Section 504 of the Rehabilitation Act of 1973 and its implementing regulation Maryam Home Health LLC. WILL NOT, DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF HANDICAP. In accordance with the Age Discrimination Act of 1975 and its implementing regulation, Maryam Home Health LLC. WILL NOT, DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF AGE in the provision of services, unless age is a factor necessary to the normal operation or the achievement of any statutory objective. In accordance with the Americans with Disabilities Act of 1992 (42 USC §12101) and its implementing regulations, (private employers with more than 25 agency personnel), Maryam Home Health LLC. WILL NOT, DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF DISABILITY. A disability is a physical or mental impairment that substantially limits a major life activity, or for which there is a record of impairment or which causes the individual to be regarded as impaired.
The information that I have given is true and accurate to the best of my knowledge.
Signature of Applicant
Date
MM slash DD slash YYYY
AGENCY MANAGEMENT NOTES: